Leveraging Telehealth for Justice-Involved Individuals: Expanding Access to Mental and Substance Use

Leveraging Telehealth for Justice-Involved Individuals: Expanding Access to Mental and Substance Use


– [Dr. Stein] Hi, good
afternoon, everyone. Thank you for joining us
here at the GAINS Center for our national webinar
on Leveraging Telehealth for Justice-Involved
Individuals: Expanding Access to Mental and Substance
Use Disorder Treatment. We are excited to partner with RSAT, Residential Substance Abuse Treatment, to provide this webinar. I am Dr. Melissa Stein,
a research associate, Senior Research Associate at
Policy Research Associates and the lead for communications
out of the GAINS Center. I have a few housekeeping remarks. First, the views, opinions, and content expressed in this
presentation and discussion do not necessarily reflect the
views, opinions, or policies of the Center for Mental Health Services, the Center for Substance Abuse Treatment, the Substance Abuse and Mental Health Services Administration, or the US Department of
Health and Human Services. Throughout all of the presentations, we welcome your questions. You’ll see on the right
side of your screen there is a Q&A portal. Just click on that to expand it and then you can enter
in questions as you wish throughout the presentations and at the conclusion
of the last presentation we will address as many
questions as time permits. You’ll also see a couple of polls pop up here at the beginning of the webinar as well as at the end and we really appreciate your
participation in these polls. The webinar is being recorded
and we will share slides directly to everyone who has
registered for this webinar in a, hopefully in a few days. And we also will let you know when the recording of this webinar is posted to the SAMHSA YouTube channel. And finally, we have a
certificate of attendance that’s available for download
at the end of the webinar. This is only for personal use. At this time, we are not
able to offer CEU credits. Just a quick look at our agenda. We have opening remarks from Jon Berg, the Senior Public Advisor at SAMHSA. Then we have three presentations
coming from Dr. Lin, Dr. Moore, and Dr. Morrone, who will be sharing more about telehealth at various levels. We will end with a time for Q&A. But first, I’ll hand it over to Jon Berg for some opening remarks. Jon. – [Jon] Thank you, Dr. Stein. Welcome to today’s webinar,
Leveraging Telehealth for Justice-Involved
Individuals: Expanding Access to Mental and Substance
Use Disorder Treatment. We appreciate you taking
time today to participate in today’s informative webinar. The opioid crisis continues
to ravage US communities with overdose deaths. The impact of opioid use on individuals transitioning from jail or
prison back to the community is overwhelmingly negative. Outcomes include higher rates of returning to the criminal justice
system, harm to families, negative public health effects such as the transmission of
infectious diseases and death. Within three months of
release from custody, 75% of formerly incarcerated individuals with an opioid use disorder
relapse to opioid use and approximately 40%-50%
are arrested for a new crime within the first year. SAMHSA is interested in
promoting policies and practices to lower the risk of overdose for persons with opioid use disorder who are or have been in contact with the criminal justice systems. Telehealth and telemedicine
is a promising practice to positively impact the field by increasing the capacity
of the justice system to respond to the opioid
crisis through increased access to medication-assisted treatment
to reduce opioid relapse and overdose. Rural areas have difficulty
providing treatment services for justice-involved individuals due to the lack of physicians
and treatment providers and difficulty with
access for the services that are available due to the need for clients
to travel great distances. However, urban and suburban
areas have similar issues providing treatment services to clients due to the lack of and
cost of transportation and the time clients
must be away from work and other required
activities during the day to participate in MAT and
other treatment services. Today’s presenters will provide ways to incorporate telemedicine
into treatment programming for substance use and
mental health disorders including how to expand access to medication-assisted treatment and they will discuss
implementation best practices and barriers. We are pleased to have Dr. Allison Lin, Dr. David Moore, and Dr. William Morrone present on this very important topic and I want to thank them
for taking time today to share their expertise. I would also like to
thank the GAINS Center and the staff for their work in developing and
facilitating today’s webinar. At this time, I will turn
it back to Dr. Stein. – [Dr. Stein] Thank you so much. Now I’d just like to briefly
introduce our presenters for today’s webinar. First we have Dr. Allison Lin who is an addiction psychiatrist
and assistant professor in the Department of Psychiatry at the University of
Michigan Medical School. She is a research
investigator at the VA Center for Clinical Management
Research in Michigan. And she specializes in
telehealth interventions to improve access to
evidence-based treatments and other interventions related
to substance use disorders. Dr. David Moore is a psychiatrist
at the VA Connecticut and he directs the VISN
1 Clinical Resource Hub. He is an assistant professor of psychiatry at Yale University School of Medicine. He serves as multiple
principle investigator in the VA Quality Enhancement
Research Initiative Consortium to Disseminate and
Understand Implementation of Opioid Use Disorder Treatment. And Dr. William Morrone
is the medical director at Recovery Pathways in Michigan. This organization provides telehealth and face-to-face clinical services for people with substance use disorders in Isabella county, Michigan. This includes the Saginaw
Chippewa tribal members, drug court participants, and those residing in the local jail. He is an associate professor of Family and Community Medicine at Michigan State University and formerly served as program
director of Family Medicine at Synergy Medical Education Alliance with Central Michigan University. He also serves as an investigator in a naloxone distribution program and also serves as director
of the Saginaw Chippewa Tribal Family Court and commissioner on the Michigan Governor’s
Impaired Driving Commission. We also have a number of disclosures
and once the poll has ended, we’ll be able to see who all is able, who has joined us from across the country. We see a majority of you are
joining from urban settings, however, we do see some folks joining from suburban and rural locations, which is very encouraging to see. We also see that a number of you are joining us from
corrections, government, community-based providers and a number of other types agencies across these sequential intercept model. Thank you so much for joining us today and now I’m going to
turn it over to Dr. Lin to kick off our presentations. Dr. Lin. – [Dr. Lin] Great, thank you so much. Can you guys hear me okay? – [Dr. Stein] Yes. – [Dr. Lin] Okay. Thanks for that introduction. I’m really excited to be a presenter today and I think this is a particularly
interesting, important, and also exciting topic to
be discussing with everybody. As mentioned, I’m an addiction
psychiatrist and researcher at the Anne Arbor VA and
the University of Michigan. Today I will be talking about telemedicine-delivered
treatment interventions for substance use disorders. In this context, I serve
both as a clinician, so I have experience seeing
my patients via telemedicine, specifically within the VA system. And also a researcher
and most of my research is really focused on the area
of both increasing quality or improving quality as
well as improving access to treatment for patients with opioid and other substance use disorders, including through the use of telemedicine. Today I will start by first reviewing some of the background information. What most of us probably
already have a sense of but really specifically focusing
on the current challenges and substance use
disorder treatment access and the importance of finding new ways to expand treatment access. Second, why telemedicine
is a particularly promising mode of treatment delivery
in order to expand access. And then really to review the evidence that we have so far from the research that we know about so far, specifically using a
systematic review I published on this topic. And then I will start
discussing telemedicine for opioid use disorder but
really pass it on to Dr. Moore, who will specifically
discuss kind of the intrinsic or the logistics and the
specifics of using telemedicine to deliver buprenorphine treatment for veterans with patient,
veterans with opioid use disorder and the VA. I’m happy to answer any further questions, so I would be excited to see any questions in the comment box. All right. A lot of folks here have
probably seen this figure distributed by the CDC which depicts the opioid overdose trends across different types of opioids. But still a good starting point
and a good point to review. What we know is that in the
2000s we really began to see that huge increase in overdoses related to prescription
opioids which is represented by that top light green line and labeled by the natural and semisynthetic opioids. But what we’ve really seen
over the last five years or so is the trend has been
shifting dramatically. Now in recent years,
overdoses on illicit opioids, street opioids, specifically
heroin and synthetic fentanyls, have sort of passed overdoses related to prescription opioids. Overall, this I think
really truly emphasizes the critical importance of delivering effective
medication treatments to patients who have developed
an opioid use disorder, which is probably the
most important risk factor for overdose. And we know that these
treatments have specifically been associated with reductions
in overdose mortality. At the same time, although
many of us talk a lot about the opioid epidemic, I
really think it’s important to emphasize that it’s not just opioids. We’ve also seen dramatic increase in overdose mortality
rates related to other substance use disorders,
particularly stimulants, including cocaine and meth. This figure here, also from the CDC, shows the recent dramatic
increase in overdose deaths related to stimulants both among patients who were using opioids and stimulants but also just stimulants alone. Again, this really emphasizes
the critical importance of providing treatments
and helping patients who had developed a multitude
of substance use disorders. Given kind of this clear
and pressing importance of delivering effective
substance use disorder treatment to patients, it’s also
important for us to understand why aren’t they receiving? What are the most
important barriers to care? For me, it’s really helpful
to think about these barriers under the trifecta of barriers related to, number one, stigma, both
patients themselves, but also really from society
and treatment facilities and many other social contexts. Second, related to the underlying illness and symptoms of addiction where by the nature of the illness, motivation to stop using,
motivation to engage in treatment might be affected. And finally, and most importantly I think, is the thing that we
can also directly impact is the limited access and accessibility and other system-related
barriers for patients who engage in treatment. We know from a national
survey of drug use and health published by SAMHSA on an annual basis that these are all reasons
that patients themselves have reported as major reasons
why they have difficulty engaging in treatment. I also want to specifically touch up on the criminal justice population, which is so critical, both
in our presentation today but really critical for all patients with substance use disorders. We know that there are further challenges including much higher prevalence
of substance use disorders in the criminal justice population. From prior research
surveys, there are estimates as high as 2/3 of jail
detainees meet criteria for alcohol or other
substance use disorders. However, on the other hand,
fewer people in jail and prisons currently receive treatment, including evidence-based
medication treatment. We know that’s starting to
change in some areas locally, however, there’s quite a lot
more that we can be doing. And the last one I think’s really critical is that the risk for negative consequences is particularly high for
the incarcerated population, especially during those
transition periods. We know that the risk for
overdose death is much higher during the initial months after
release from jail or prison due to the loss of tolerance and the high likelihood of relapse. I think all of this together, so the higher prevalence
of substance use disorders, the further challenges with treatment, and the higher risk for
overdose in this population really necessitates further
interventions or ideas about improving treatment. Lastly, we also know that the
use of medication treatment for those who are incarcerated
is actually associated with improved outcomes like other substance using populations. We know that medication
treatment is associated with reduced risk for overdose and substance use after release. And those who are initiated
actually onto treatment before their release, so
within jails and prisons, are actually more likely to
be engaged in care longterm. This is really important
because that’s actually one of the most key
outcomes that we think about is not just whether or not their
substance use is decreasing but really the best
predictor of overall success is whether or not patients remain engaged in treatment longterm. The fact that if initiating treatment while they’re in jail and
prison improves this outcome, that’s a really important
and a positive sign. Given all of these challenges, however, understandably there’s a lot of interest to develop new approaches
in delivering treatment. And likely multiple
approaches will be needed including increasing providers
in low treatment facilities, including low treatment jails and prisons, integrating substance use
disorder in non-tradition settings including primary care,
general mental health care, and other settings. And finally, expanding
the use of telemedicine, which is what we’ll be focusing on today. Likely all of these strategies
are going to be needed and in combination. Now, to start, I first
want to define what I mean by the term telemedicine because sometimes this can be confusing and it’s applied to a number of different modalities. What I mean, and I think
what we all mean today, in particular, by telemedicine
is that we’re focused on the term for the use of synchronous or live videoconferencing. Some people think of it as Skype, communicating through
something like Skype, but using those types of technologies for direct patient care delivery
by a clinician or provider in one location to patients
in another location. It’s also important because
this is the modality that’s most oftentimes
reimbursable by different payers. It could be included to be used for delivering medication treatment as well as psychotherapy. In addition though, the word
telemedicine sometimes is used to refer to other types of approaches including what’s called asynchronous or store and forward technology. For example, a provider
reviewing an electronic image or something like that
but not seeing a patient in real time. There’s also numerous other important technology-based strategies
including phone, text, web-based applications that are more of auxiliary
tools to treatment that we will not be
focusing on today as much. And before I start describing
the evidence that we have from the research for
telemedicine treatment for substance use disorders,
I will first remind us and briefly review the
evidence of telemedicine for other chronic illnesses. We know that we’ve had
a wealth of studies, probably hundreds of studies dating back over the last two decades supporting the use of
telemedicine for treating multiple chronic medical conditions, in particular, including
mental health conditions like depression, PTSD, and others. I’ll briefly kind of highlight
some of these studies. This includes a very early study done by Ruskin and colleagues in 2004 where they randomized patients to either receiving their depression treatment, which included both a medication component and also meeting with a therapist, comparing people who got
their treatments in-person versus via telemedicine
to another location. And they found that the telemedicine arm was just as effective in
terms of depression outcomes and that it was also similarly associated with high levels of patient satisfaction compared to the traditional
in-person treatment. There’s also evidence not
just from these smaller, randomized controlled
studies in singles sites but for depression treatment, for example, from very large implementation trials including this large implementation study published by John Fortney
and colleagues in 2012 where telemedicine collaborative
care for depression, so meaning using social work, master’s level social worker who’s trained at managing depression and helping to kind of understanding
patient needs and such and treating depression. This was implemented across
three large VA medical centers and 11 of their affiliated
community clinics. They found that this intervention was associated with high satisfaction from both staff and patients and that actually most importantly the majority of the clinics actually chose to maintain the program
after the study ended. All of those are really helpful signs to indicate that telemedicine
interventions in general can be very effective, can be associated with high satisfaction in patients and providers, and can actually be implemented
in real world settings. However, although there
have been many studies examining telemedicine for
other chronic diseases, we do have more limited
research when it comes to substance use disorders
and this is what motivated myself and a number of colleagues to conduct a recent systematic
review that was published in the Journal of
Substance Abuse Treatment. We took, I’ll briefly introduce the study and describe some of our findings. We took a very broad inclusion criteria due to the limited number of studies that have been published in this area. We reviewed the literature
for published manuscripts and conference proceedings
over a 20-year period from 1998 to October of 2018. We included studies that addressed any substance use disorders, including nicotine use disorder, and we specifically focused
on the type of telemedicine that I mentioned before,
so direct patient care. We did not only included
randomized controlled trials but we also looked at
retrospective studies, observational data studies, and et cetera to get a better understanding overall. What we found was that in total though there were only 13 studies
that met all of our inclusion and exclusion criteria. And among these 13 studies, three studies focused on
tobacco use, five on alcohol, and five on treatment
of opioid use disorders. Today I will briefly summarize the studies focusing on alcohol and
opioid use disorders here. And among the telemedicine studies that we found for alcohol use disorders, all five were focused on
psychotherapy treatments and none included medication components. The findings were somewhat mixed. In a study by folks in Denmark, patients were randomized to
have the option of receiving some of their psychotherapy
sessions via telemedicine to their home or to any other location. That intervention was
associated with lower rates of premature dropout than
patients who have to receive all of their sessions in-person. In contrast, in another study
by Staten and colleagues, rural risky alcohol users were randomized to either receiving their
telemedicine deliver motivational psychotherapy intervention either via telemedicine or in-person and they did not find
significant differences in alcohol-related outcomes. Now, moving to telemedicine studies for opioid use disorders, there were two studies focused on telemedicine-delivered
psychotherapy interventions to patients and three
studies that also included a medication component. Both of the psychotherapy
studies were fairly small. Those were both randomized
controlled trials. They found no difference in
number of sessions attended and no difference in number of percent of drug-positive urines
comparing telemedicine to traditional in-person treatment. And they also found that the
participants and therapists had high ratings of therapeutic alliance. There were three additional
telemedicine studies and I think what a lot of folks
here might be interested in that focused on opioid
use disorder treatment that also included medication delivery. None of these were randomized trials. All of these involved
looking at an intervention with patients located in a rural clinic with a medication provider located at a separate clinic site. Treatment not only involved the prescribing of the medication but also involved other components such as conducting and
following urine drug screens. The largest of these
studies in all of these were just kind of
looking back at the data. They were not randomized trials. The largest was a study conducted by folks in Ontario, Canada, which has been doing this for longest. They’ve been actually doing
telemedicine OUD treatment for many, many years. They found that compared
to patients received most of their visits in-person, those who received their
visits via telemedicine actually had better retention at one year. Similarly, folks in West
Virginia have found that other substance-related outcomes like abstinence and
retention were quite similar between in-person and
telemedicine treated patients. In summary, what I want to
say is that although we have a lot of studies, hundreds probably, supporting telemedicine use for other chronic medical conditions, the data for substance use
disorders is more limited. That doesn’t mean, that it,
it’s just that we don’t know yet and probably some more
research needs to be conducted. However, the ones that we have to date for self-infused disorders, there are some indications
that telemedicine, especially for psychotherapy interventions for alcohol and opioid use disorders, might be really promising. However, there are a
few things to consider. For example, the
availability and logistics of telemedicine technology,
clinician comfort level, those are kind of the key things, I think, in terms of thinking
about implementing it. And I believe these are
also some of the things that Dr. Moore and Dr. Morrone
will focus on later on. Also, the other key thing
is, most importantly, I think it’s important to think about what is the alternative? If you have a patient
somewhere who really has no other treatment options, meaning they can’t see
another provider in-person, if the alternative is no treatment, then telemedicine is likely going to be a much better alternative to that. One second. All right, one last study that
I wanted to briefly describe. In addition to kind of
some of the resources I mentioned before,
there was a recent study that examined real world
use of telemedicine for patients with substance use disorders that looked at data from
a private insurance plan that spanned across the US. They found that the use of telemedicine has increased substantially
over the last decade or so but the growth has been slower
for substance use disorders than for tele-mental health. My point in saying this
is to emphasize that we, many health system providers, have been able to implement telehealth for mental health disorders but doing so for substance use disorders
is beginning to happen. When they looked at the use of telehealth among patients with
substance use disorders, they found that telemedicine
was used primarily to complement and not necessarily
to replace in-person care. Patients oftentimes had
a combination of both in-person visits as well
as telehealth visits and it was more often used by patients with more severe substance use disorders. Now I want to transition
to focusing on telemedicine for medication treatment
for opioid use disorder and that’s really been a
particular interest for many of us. Just to remind us, especially
with opioid use disorders, the medication buprenorphine
is a controlled medication and currently requires providers
be X-waivered by the DEA. This is one of the things that contribute to challenges with access. This is a map of the US with
all the counties delineated. What we see is that the counties in red are counties with not a
single opioid use disorder medication provider. This includes buprenorphine, methadone, and long-acting naltrexone. These are counties with not
a single publicly available opioid use disorder treatment. And this really continues to
emphasize the need that we have to expand treatment access,
in particular to rural areas but also to a lot of
other regions as well. I also will briefly touch upon this. I think probably a lot
of folks on the call know this already but in terms
of the effective medications that we have for opioid use disorder, these are the three known
medication treatments that are effective for OUD. These are the medications
methadone, buprenorphine, and long acting naltrexone. Methadone’s been around the longest, approved since the 1970s. But for opioid use disorder treatment, it is only can be dispensed in a DEA-approved methadone clinic. These clinics oftentimes require
patients to present daily to get dosed for their medication so they don’t just get a
prescription to take home. And the biggest challenge is there are very, very
few methadone clinics. Dr. Morrone might mention
this but there’s really not a methadone clinic as far
as I know of, for example, for the entire upper
peninsula of Michigan, which covers many hundreds of miles and thus it’s very difficult sometimes for patients to access. In addition to that, the
medication buprenorphine, since 2004, has been
approved for the treatment of opioid use disorder
for someone, a prescriber, who has an X-waiver. This can be prescribed actually
during normal office visits. The goal now of treatment with either methadone or buprenorphine, which are both opioids themselves, is that when dosed appropriately, patients taking these doses will have reduced cravings for opioids, they’ll no longer experience or have the high chance of experiencing euphoric effects of opioids, and finally, these medications will alleviate symptoms of opioid withdrawal. The overall goal of
all of these treatments is to really help
patients reduce behaviors and other symptoms of
underlying opioid use disorder and help them return to functioning. The third medication is
long acting naltrexone, which works differently. It blocks the effects of opioids. It comes in both once a day and a long acting injectable formulation. This is a newer medication
that’s also been shown to be potentially effective
for opioid use disorders. Across all, many, many,
many decades of research that we have for these treatments, especially for the medications
buprenorphine and methadone, we know that these treatments
are very effective. They reduce opioid use, they’re associated with many other important positive outcomes
such reductions in rates of HIV and Hep C transmission. Data showing that they
can be cost effective and associated with
improved quality of life and functioning for patients. The bottom line that we know
is that these medications are the most effective treatments
that we have for patients and that patients
experience much higher rates of negative consequences such as overdose when they do not have
access to these treatments. Then finally, I will move
to kind of the things that we have to start thinking about when it comes to delivering
these medications via telemedicine. There are a number of
specific things to consider when implementing telemedicine for opioid use disorder treatment and most of us will be focusing specifically on buprenorphine
because it can be prescribed in office-based settings. Much of these things to consider though really are about the logistics
of treatment delivery. In addition though,
it’s also about adhering to federal and state regulations. The things that are
important to really consider are the logistics of
how to monitor patients from inductions or starting treatment, other logistics like
how are you going to do when conducting your toxicology screens, if it’s at a lab, how do
you get those results, but are there other ways
to obtain the same data? Finally, how to do measurements, so assessing for withdrawal symptoms, conducting COWS assessments
and things like that via telemedicine. And also the staffing available to help you deliver these treatments including if there’s also staff available to deliver psychotherapy patients. I think the main thing I
want to emphasize is that doing this is possible, it’s just a number of key
logistic things to think about. The last thing that will
very much also emphasize is the importance of adhering to state and federal regulations, especially in the use of buprenorphine for opioid use disorder treatment. I will basically first touch
upon one of the key regulations that a lot of folks have
probably heard about. The most applicable federal
regulation is the Ryan Haight Online Pharmacy Act of 2008 which applies to any prescribing
controlled medications when a provider and patient
is not in the same location. Under this act,
prescriptions must be issued for legitimate medical
purposes under the usual course of professional practice. And except for under certain exemptions, a provider must have conducted an initial face-to-face visit first. This does apply, for
example, to the treatment of using of buprenorphine for
telemedicine for patients. What this implies is that unless
certain exceptions are met folks have to have an
initial face-to-face visit. Some of these exceptions
include things like emergencies or cross-coverage scenarios
that we might have a chance to go into later on. They also include whether or
not a patient’s presenting in a facility with their own DEA license. However, the basic thing
is I want to mention that Ryan Haight could be addressed with an initial in-person
visit as long as the provider is acting in their usual
course of practice. All right, that ends my portion. I’m going to pass kind of
the baton to Dr. Moore, who I also work with, to discuss
some of the more detailed and logistics of conducting
telemedicine-based treatment. – [Dr. Moore] Hi everybody. Can everyone hear me okay? – [Dr. Stein] Yes, we can hear you. – [Dr. Moore] Okay, great. I’m going to talk a little bit about kind of different models
for how telemedicine can be brought into really a health system or a system of care. This slide right here
shows kind of what’s the, what some folks call
the stepped care model for management of opiate use disorder. It’s based on the idea
that not all patients necessarily need the same type of care or the same intensity of care isn’t inappropriate for everyone and that when thinking about
this on a system level, we really want to kind of not give, realizing that provider
resources might be scarce, we want to make sure we reserve the correct types of providers
for the right situations. At the very bottom step is
the idea of self-management. This is where there’s not a
medication-assisted treatment, or an MOUD, a medication
for opiate use disorder, for the patient with who has, who is struggling with opioid use. Self-help and 12-step
models often fall in this, this category. What we’re really going
to be talking about are step one and step two. This is where there’s
recognition that the patient requires some type of medication
to help support recovery from opiate use. It’s based on the idea also that a lot of the treatment effects comes from that medication. A lot of the studies have found that kind of regardless of the situation where the medication’s prescribed, there is generally a pretty good response or it’s not a complete
recovery guaranteed, but most of the treatment
effect comes from the medication that is, that is treating
the opiate use disorder. The first step is often called addiction-focused medical management. The idea is that primary care or general mental health providers can provide the treatment. Step two is reserved for specialty care. Addiction specialists, so folks who have completed
specialty addiction training beyond the X-waiver, maybe
more intense setting, like addiction groups, IOPs
or even residential programs. Sorry. Here we go. The question is how can we use telehealth to support these different steps. One is you want to remove the barriers to treatment. In a health system, one
thing that can be done are things like removing pharmacy barriers or artificial things that
might prevent folks who are working in a health system to prescribe. Looking at the VA, one thing we’ve noticed is sometimes primary care
providers haven’t been allowed to provide buprenorphine. There’s been a big push within the VA to take away that artificial
barrier to prescribing and the idea is that many
patients are appropriate for primary care provided
buprenorphine treatment. Another way is to provide
incentives to people who are already there. Performance pay, kind
of changes in panel size if you’re prescribing buprenorphine. Those have been found to be
effective ways to do this. And then also increasing support. Increasing access to trainings and then things like Project ECHO, which is an educational
kind of group learning, case-based initiative to
get people more comfortable with prescribing. Finally, you can actually
use telemedicine. This is what Allison was describing. Having a remote provider
prescribe into a setting. That prescriber could be
a primary care physician or provider, a mental health provider, they can use tele-care
management to help support buprenorphine prescribing. Or in some cases it might
even be a step two provider, someone who’s a specialist, someone to maybe help
support groups or IOPs to do therapy to support prescribing, or a specialized addiction provider for really complicated patients. To prescribe buprenorphine into a setting you need some very basic things. You need a DEA-waivered provider, someone that’s completed
the X-waiver training. They can be remote. You need to have some type of nursing or clinical staff onsite when prescribing something like buprenorphine because it is a partial agonist opioid so
it’s a controlled substance. It’s possible for it to have side effects. No medication is without risk. You need someone to be
able to do vital signs, things like that, to monitor the process of
starting the medicine also, especially when starting a new medication, that’s when you’re most
likely to have side effects. And if starting it is in the
context of opioid withdrawal, it’s very important to have someone onsite to manage the withdrawal
symptoms and support the patient who is getting started on the medication. It’s required to be able to
monitor the prescription drug, the PDMP, the prescription
drug monitoring program. Every state has one and those are used to keep track of controlled substances. You need a reliable pharmacy. These are not medications
where a gap in treatment is acceptable so there either
has to be a pharmacy onsite or a way of delivering
that medication to the site that’s reliable and timely. There has to be ability
to do laboratory testing. The very basic, the most
basic is urine drug screening. It doesn’t necessarily
have to be point of care but something where kind of
the urine can be collected when it’s needed and
then get the results back in a timely fashion. It’s required for buprenorphine also to be able to refer to
a higher level of care. That if there’s something that makes the patient more complex and they’re not doing
well, there’s some way of kind of keeping them in treatment if you’re going to prescribe it. For tele-prescribing, and
so all these things are true for whether you’re
tele-prescribing or not, but for tele-prescribing
what you need to do is two extra things, is really
pay attention to the laws. You need to comply with
the Ryan Haight Act, that’s the federal law
that regulates all this. And then prescri-, compliance
with the local state laws and those are variable between sites. This is an example from our clinic. Our clinic is remote,
it’s based in Connecticut, and we help a health system in Maine support their buprenorphine efforts. One thing we’ve been able
to do is to prescribe into large clinics. Large sites that have a lot of
support staff on the ground, a lot of nursing and technicians who can, and primary care providers who can kind of manage a large number of
patients and a large case load. What was lacking was an
X-waivered prescriber to treat those patients. And so our X-waivered prescriber, our buprenorphine prescriber,
was able to manage patients with the support of quite
a few staff on the ground. What’s nice about this
arrangement is that you can prescribe into groups. You can also very easily
do a monitored induction or a monitored initiation of buprenorphine since there’s plenty
of staff on the ground to help monitor complex patients. The telehealth provider
who is based in Connecticut can do a video visit with the patient in either Augusta or Bangor
and do the interview, kind of observe how they look, and then work with the
nursing staff on the ground to make sure that they’re
getting started on medications. Another way of thinking about this is management of less complex patients maybe at multiple sites. We also staff three small
highly rural clinics in northern Maine where there
are no X-waivered providers. There’s less nursing staff on the ground so it’s not always appropriate for more medically complex patients. But one provider is able
to staff multiple clinics where no one clinic would have
enough patients any given day to really kind of dedicate a provider to so our providers can flexibly
go between different sites and treat patients. Usually we use what’s called an unmonitored buprenorphine
induction or initiation. The idea is that these are for less medically complex patients, they are struggling
with opiate use disorder and we can basically
prescribe the medicine and then they monitor their own symptoms. One example of a patient who presented to one of these clinics
actually without warning, so they presented to their
primary care provider, a 30-year-old gentleman, and
he was in opiate withdrawal with all the symptoms of it
and really very uncomfortable. Their primary care team
was able to call our clinic in (mumbles) and let us know
that someone had presented. They were seen first by
the primary care provider and then we were able to video
in and get a good history and start the medication at that time. He was able to go home and
then start buprenorphine on his own and then present the next day. And then, that happened in one
site and then that provider was able to switch to another clinic to do a follow up visit for someone else. It’s really quite flexible
and it’s a good way of making sure that kind of
scarce resources are shared over a large geographic area. Here’s a disadvantage. We also staff clinics in New Hampshire but we cannot currently
prescribe buprenorphine into these sites. New Hampshire is an example of a state that has a state law that
prevents tele-prescribing of controlled substances
like buprenorphine, except for very rare circumstances. They actually have to be
seen at a SAMHSA-certified opiate treatment program and
by the prescriber doing it in-person before
tele-prescribing can happen. It might be doable for a provider in the State of New Hampshire but not from our remote clinic. It’s really important when
doing this to pay attention to the state laws. This may change a little
bit in the coming year. The DEA is going to create a new rule on what tele-prescribers can and cannot do but we don’t have that rule yet. The other big advantage to
this is that it’s very flexible in terms of the lives of our patients. It’s kind of, so I don’t work
in a correctional setting but I know that when people are released either from jail or prison
and they rejoin the community that they may not stay in one area. They may move because of work or family and so one example is a
patient that I was working with in Caribou, Maine. I started him on buprenorphine there. He took a job down in Augusta and Portland and then eventually came back to Caribou but I was able to follow
him at multiple sites through telemedicine and there
were no delays in treatment. This is actually really important in supporting his early recovery. In summary, there’s different
ways of providing MAT within a kind of larger system. There, you have to be mindful
when you first start it that you have all of the kind of the building blocks in place
being able to do lab testing, having access to a pharmacy
or having a connection with the local pharmacies where you’re tele-prescribing into. There can be some barriers,
most of them are state laws but just kind of things like
the weather could be different in different sites so I have
to pay attention to the fact that Caribou, Maine may
have six foot of snow pack by the time January rolls around and so it might hard for the patients to get into the clinics on some days. Thinking about how you’re going to kind of handle those kind of
geographic differences. But it can be really rewarding also because often a lot of the communities that you tele-prescribe into, they don’t have providers
who provide buprenorphine and they’re very appreciative. They live in these towns and to see access to such an effective treatment
coming to their communities is generally a very positive response. I think that’s it. This kind of wraps up Allison
and my portion of the talk. Here’s our references. I’m going to push along
over to Dr. Morrone’s talk. – [Dr. Stein] Dr. Morrone,
I want to make sure you’re not muted as we’re
not able to hear you. – [Dr. Morrone] I was muted! I’m sorry. – [Dr. Stein] There you
are, great, wonderful. – [Dr. Morrone] Okay. All of that was fantastic groundwork laid before you to see the
forest and now I’m going to take a closer look and
show you a couple of trees and a couple of bushes and try to show you some of the fruits of telemedicine. We work in criminal
justice in the 35th Circuit in Shiawassee County, the
66th District Probation and the Saginaw Chippewa and
many people that I’ve seen in criminal justice in the last few years, I’ve seen them in my practice and it’s been very rewarding
to see people slow down. Sometimes they’re slowed down
by the criminal justice system for another look and it
helps put together the puzzle of their lives and help
them with the steps they need to take. Now the most important
thing when we get into substance use disorder are the HHS 42 CFR Part 2 Rule. The regulations serve to
protect patient records created by federally funded programs for the treatment of
substance use disorder. And SAMHSA has proposed
a revision to Part 2 to facilitate and better coordinate care for substance use
disorder which would also enhance care for opioid use disorder. These provisions will be an important part of the federal response to
our current opioid epidemic while maintaining Part 2 confidentiality. Now many people on this
call might be too young to remember medicine before HIPAA and there was a lot of common sense. Well, we just do this
because it’s common sense or we don’t do this
because of common sense. And the confidentiality that we have today is built off of 42 CFR’s architecture pre-HIPAA. This confidentiality existed in the 42 CFR so people sometimes wonder why
we can’t get certain records or why certain providers
need to approach each other in a special way and
it’s because before HIPAA this was a very important
part of the treatment, the confidentiality. There was no national movement in the American Medical Association or some of our state bureaucracies so it had to be a federal law
to protect people in treatment because we did not want
the stigma to prevent the fruits of treatment. The 42 CFR protected confidentiality. Now, what we look at and we say this, it’s not going to change a
lot under the new Part 2, it will not alter the basic framework for the confidentiality
that has been laid out and what we know is 42 CFR is one of the primary
stepping stones to information coming in and out of
opioid treatment programs, methadone clinics. The protection of substance
use disorder patients is created because we have
these federally funded programs so we need federally
based guidelines and laws. Part 2 will continue to
prohibit law enforcement use of substance use disorder patient records in criminal prosecution
against the patient. It will continue to
restrict the disclosure of substance use disorder
treatment records without the patient’s
consent and that makes sense. But we didn’t have this
concept 30 years ago when we really needed
this kind of assurance that substance use disorder
could continue and protect, 42 CFR did that. HIPAA did not exist 30 years ago and it was the 42 CFR
that allowed us that. There were difference
phases of HIPAA, too. Part of HIPAA related
to billing and 42 CFR conserves confidentiality. Here’s the billing footprint
of Recovery Pathways clinics. Based on the counties in
Michigan that we serve, we bill patients from 458 zip codes. Now we don’t do this in one center, we have nine centers in seven counties and we’re able to reach out. But some of these counties
have absolutely no providers and we can’t be there seven days a week. We travel. We even have a new mobile unit. How do we get to that site? And those patients, they
could come to our office but it’s too far. Substance use disorder patients often have transportation problems. We put sites out and those sites gather people and sometimes the provider
is not able to be there. We have a case worker or a
therapist that is pre-placed and we have face-to-face service
in community mental health in the Community Mental Health Center and we have telemedicine service in the Community Mental Health Center, and we’ve also taken
telemedicine into the jail and we’ve offered
naltrexone extended release, 380 milligram, in the jail connected to our telemedicine visits. Administered, in the beginning
I would go into the jail and give the shots myself
but now I have a jail nurse that does that. Some of the effects that
we’ve seen in Isabella, we would look back to 2014,
it was like a pre-heroin, pre-fentanyl baseline of what
opioid overdose deaths were and it was about three. And the fentanyl hit the
heroin supply in 2015 and deaths skyrocketed to 13. And we opened up in an adjacent county so people could travel
across the county line to come to us so maybe
that’s not significant. But in 2017 and ’18, we had
embedded face-to-face services and telemedicine in Isabella County and our opioid overdose death
rates were eight and eight, two years back-to-back. Now, I recently did the data and the 11 out of 12 months
data for Isabella County with enhanced services in
the tribe, in the jail, using telemedicine and face-to-face in community mental health, we’ve gone from 13
overdoses in 2015 to two for a partial year. For 11 out of 12 months we’ve only had two and I think it is an example
of treatment saves lives. Telehealth originating sites
are where the patient is. The beneficiary gets services
through that asynchronous or synchronous system. All of our situations are synchronous, face-to-face, realtime. A beneficiary must go
to this originating site and before this year, it
couldn’t be your home, but there were some
changes in July, it could. It can be the jail where they are, it can be a mobile unit, it
can be community mental health. And that originating site has changed so we’ve done it on tribal grounds, we’ve done it at community mental health, and we’ve done it in criminal justice. At the telehealth originating site, it could be classified
a physician’s office, a hospital, critical access
hospital, rural health clinic, et cetera. And the distant site,
which is our provider, if it’s me, it’s a physician, but we have nurse practitioners,
physician’s assistants. A new and interesting change
would be nurse midwives, clinical nurse specialists,
and I’m recruiting a new registered nurse anesthetist
to come on for SUD training. Like we had in the very beginning, real time communication
between the provider at the distant site and the beneficiary at the originating site. Transmitting medical information, we have some of the documentation up front like the prescription
drug monitoring program, we can print those out ahead of time. Here’s where one of the
biggest limitations we saw. Dr. Moore was excellent
when he pointed out how can we take away
some of these barriers and he pointed to the pharmacy
and he pointed to providers and distance and the
time to see a provider. In telehealth our biggest
problem has been WiFi, rate limiting. Inside the criminal justice
system, the buildings, the jails, the prisons, they’re
really not built for that and we don’t, at this time, contractually share their
services so we have to go in with jet packs or little
towers and we monitor, there’s like an iPad there
and I have an iPad outside. We can have the software,
we can have the tablets but the rate limiting
step has been the WiFi and it’s just not broad
enough and strong enough for everything we do. When we pull up the screen, here you see me showing some naloxone, we have a video part and then a de-identified
patient information shows you kind of what the
medical list looks like so we can look at patients
and look at their lists and answer their questions. Graphically, this is the originating site and the distant site. The drug court and the jail is on the left and the telehealth provider,
we can be 50 miles away, we can be 150 miles away, and the benefit is the
distant site can be serving with a provider in one
place three different sites in one jail, three different jails. A jail and a tribal site, or a jail, a tribal site, and a community mental health site. The provider doesn’t
travel and that takes, travel time, which is dead clinical time, and allows more patient contact and that’s what we really like about it. We need, in these therapeutic alliances, to break through the screen
and offer non-judgmental, curious, empathetic care,
recognize adversity. Sometimes people, they
may carry some shame or if they know you, you
may have had a relationship that was toxic a year
ago and now you’re back helping to treat them
and those kind of things are important. Honesty. Share your goals, what is
the goal of the session? Sometimes people will ask me
for buprenorphine right there and I’ll say, well, I can’t
give it to you in jail. You’re going to be here a while, let’s start with naltrexone
extended release. And we can assure people
that our objective is a concern for his or her
health and that’s primary. We go through the DSM V to make sure everybody that we’re seeing
really isn’t just mental health. It’s mental health with
substance use disorder and we’re not really treating pain. Sometimes get that, the
people get that confused that we’re not really there for pain and we have to make that clear. We’re talking about loss of
control, physiological effects, and consequences based in DSM V and we score all of our patients. To emphasize where we go, telehealth pharmacological
management is the focus of our telehealth. I have the therapist onsite face-to-face. They’re the person running my IT hardware. I have a case manager, I have a therapist, so they’re getting that because those laws are really not gelled. They’re not codified
whereas telehealth laws are in our state. We look at drug testing. This bag is blisters left over from a buprenorphine naloxone
product that we count in our settings when we go to the tribe or we go to community mental health and this is a method to prevent diversion. And that’s just as
important as drug testing. Prescription drug monitoring, there’s an example at the bottom. We use that to see how our
patients have been traveling to other physicians or not. In summary, the initial
evaluation is comprised of building a therapeutic
alliance and obtaining data through telehealth for
the treatment and planning and the initiation of
some kind of treatment. We don’t give the shot the
first day we see people. We give them time to think,
we give them more information, I answer questions,
and we come back later. Sometimes we give oral
naltrexone to help people before the injection. Important components include
the medical, psychiatric, and substance use disorder recognition. There is great variability
about how many different people practice many different ways. And at that, I will turn it back over and thank you for the opportunity. – [Dr. Stein] Thank you
so much Dr. Morrone. We will have some time for Q&A so please look at the Q&A
portal on the right side of your computer screen
and please enter in any questions you may
have as we have some time to go through those questions. I also want to make
sure that we make clear that we misspoke earlier
during the webinar. This is one webinar where
we are offering CEU credits through our partnership with RSAT. They are making this possible
and we really appreciate that. Yes, this webinar is going
to count for CEU credits and we will be sharing a link
at the end of the Q&A session through which you will be
able to access instructions around obtaining those CEU credits. We apologize for misspeaking
on that and, again, just really express our
appreciation to RSAT for their partnership
with us on this webinar. Before we get to that though, we want to go through some questions that you all have submitted throughout the two presentations. I’m just going to start at the beginning. It looks like a couple came through during the presentation
by Dr. Lin and Dr. Moore. The first one is a question
that we get a lot as MAT is an issue that is very
important across many communities in the nation. We had someone listening
in and asked are there any medication-assisted
treatments for meth users? This person noted research
in this area seems limited. Dr. Lin or Dr. Moore, would
you want to comment on that? – [Dr. Lin] I can start
and I’d be curious to hear Dr. Moore’s thoughts. I get this question all the time. I actually provide
phone-based consultation to rural providers in
the State of Michigan, especially in rural areas, meth
has been a tremendous issue. Some of it is within a
population that co-use meth as well as opioids but sometimes just within
the meth population. There was recently a systematic
review of research studies published for meth use disorder in the journal called Addiction so that’s something that
maybe folks can look into. In my knowledge and a
review in the literature, this is very few treatments
that are even promising. Many, many medications have been looked at including stimulant medications,
other antidepressants including SSRIs as well as Wellbutrin. My sense is that probably some
of the more promising options are something like Wellbutrin. I try to stay away from any
other controlled medications with a patient any addiction
so reluctant to use stimulants except in very, very
particular circumstances. The bottom line is that
medication treatments have not been very promising so far though there’s ongoing research. The treatments that I
think are underutilized and more promising are actually behavioral or psychotherapy treatments. One of the most underutilized treatments is actually contingency management. There’s also been more
research into how to implement contingency management in
different community settings as well as psychotherapy. Those are the things that I would encourage
people to consider as well. I’m sorry, one last thing. The key thing that I’ve noted in treating patients with
meth use is to really be vigilant about treating
concurrent disorders, so concurrent mental health disorders as well as other substance use disorders including opioid use
disorder with the medications we’ve discussed so far. – [Dr. Moore] Hi, this is Dave. Yeah, I kind of want to just
echo what Allison just said that there’s not a lot of strong evidence in the literature. I was at a conference last week
and they had several experts on stimulants and
methamphetamine give a talk and they said that there might
be some growing evidence, and depending on how you
look at the populations, whether it be mild versus
severe methamphetamine use, that things like Wellbutrin can help, maybe naltrexone in some settings. These are things that are
not strong evidence bases, definitely not FDA approved. There are some studies
where they maybe have seen some benefit from stimulants
but it would be a really hard thing to do to prescribe that, I think. Or it would be outside of
what I feel comfortable doing. And, yeah, contingency management, a lot of the behavioral things. But when someone does
have methamphetamine use and an opiate use disorder, so I have a couple of patients like that, really focusing on the opiate use is fine. I do not withhold
buprenorphine for patients who maybe are struggling
with methamphetamine use as long as I’m not worried
about a major safety issue or diversion. If I can feel comfortable
that there’s no diversion and they’re taking the
buprenorphine as prescribed, then I’ll continue it. I have one patient who has
not used opioids in two years, even though he does from time to time relapse on methamphetamine. And I consider that a success in some ways even though it’s not 100% success. – [Dr. Stein] I thank
you for that Dr. Moore. I believe this next question came in during Dr. Moore’s part
of the presentation so I’m not sure what rule
this person is referring to but they asked how did
you accommodate the rule for an initial F2F visit? Do you feel comfortable
responding to that? – [Dr. Moore] Ah, so, yeah.
– [Dr. Stein] Okay. That’s the question about
whether or not you have to have a face-to-face visit. This kind of gets down
to the terminology of it. Technically face-to-face for
the purpose of Ryan Haight can be a video visit. The in-person part is the most, so this is where the terminology
gets really confusing. Having an in-person in the office visit, our way around that is
that we work between DEA registered sites. Our medical center has
its own DEA registration and the small rural clinics we work in are also DEA registered. Then what that means is we can prescribe via what’s called telemedicine
in the Ryan Haight Act between these sites. I would not be able to see a patient outside of a DEA registered
site so if they were in Maine and we’re in a different clinic that did not have a DEA registration, then I would not be able to see them and prescribe buprenorphine. One thing I didn’t kind
of bring up is that buprenorphine is actually a
Schedule III medication, too, which means that since it’s Schedule III you have more refill options. You can actually refill
it up to five times in a six month period. Say you have been, you could
do different types of visits and if you’re feeling confident that they’re doing urine lab testing and they’re not diverting,
then you can still prescribe without doing a visit between DEA registered sites potentially. And it gets a little more complicated. I think the most important
rule is to remember that you can do it between
DEA registered sites as long as that state permits it. Sometimes a state may have
an extra law that may, you have to be mindful of. Hopefully that answers the question. – [Dr. Stein] All right,
thank you so much. This question I think could be answered by all three panelists. This person stated that
there is a lot of diversion going on with their sublingual suboxone alongside and in clinic drug screenings and they are wanting to consider
the buprenorphine implant. They were wondering what
are some of the barriers via telemedicine to get this prescribed, particularly in rural communities. Dr. Lin, Moore, or Morrone,
would you any of you want to respond to this? – [Dr. Moore] This is Dave Moore. The implant, we usually
shy away of the implant just because its effective
dosage is not particularly high and there’s not a good track
record on when to stop, like how long you can use
the implant or, I think, maybe Allison or the other folks
want to correct me on that. But there are other things like sublocade, which is a little
different than the implant. It’s a long-acting injectable formulation that’s every month. We have not had success
in getting it implemented because you need to have a pharmacy and a staff that can do it
but I think it would great. That’s one of our goals is
to get sublocade available in the some of the clinics we
work in, especially for folks, and a lot of our patients
have asked for it because they don’t like
taking medications. – [Dr. Lin] Yeah, I
totally agreed with that, that the sublocade is a
great potential option. I mean, the key thing here is if you’re going to
do it via telemedicine, you would need another clinic
to be set up to administer it. And the other thing is there are sometimes additional barriers, for example, insurance reimbursement and such but states are making some changes. In the State of Michigan, we recently removed
our prior authorization for buprenorphine products
including sublocade and so it makes it easier
to get to patients. But then you’d have to
make sure that you have a, for example, just a clinic
that has like the MA or nursing support to do an injection, which is not, anything gets doable. – [Dr. Morrone] And, can you hear me okay? – [Dr. Stein] Yes, I can hear you. – [Dr. Morrone] Okay, there
are two points I’d like to make about the diversion with this. Listing the sublocade
is an excellent idea. There are certain things
you want to make sure you can do to not get into trouble. When we do it, we have an agreement that the patient has to be stable, it’s part of the FDA approval, and when it’s delivered by Fed Ex or UPS, the patient gets the shot the same day because it’s a Schedule
III and many places do not have the proper licensing to have a Schedule III onsite overnight or two or three days. The patient has to know
that when that’s delivered, they get a phone call and they come and they
get the shot right away. There’s also a little bit
of pain in the injection on the sub-q side and we’ve
used a generic lidocaine cream to make it very comfortable. We have less complaints. But if you can’t get to it right away and you’re still worried about diversion, what we try to do to prevent
diversion on that site is we prescribe in five
to seven day quantities. We never really prescribe
a month at a time. And sometimes that’s enough
to help hold off diversion until you get to that. But that not having the
right license to do it and keep it overnight, you
get rid of that problem if you have all the sublocade injections on the same day it’s delivered. We can go to my refrigerator right now and I have 53 Vivitrols but we have none, we have no sublocade because
we’re trying to follow the law and licensing and regulatory
effects and the DEA have certain guidelines about
what you can keep onsite. But sublocade is exactly what
the other two panelists said, it is part of the answer on this. But make sure you don’t
get in trouble with the law in storing it. – [Dr. Stein] All right,
thank you so much. We’ve had a couple of questions come in about using telemedicine in
correctional settings and, in particular, using
telemedicine in conjunction with providing MAT in correctional settings. Would any of the
presenters feel comfortable sharing more about that,
particularly how to bridge the gap to accessing technology within
correctional facilities? – [Dr. Morrone] I can take
that to show what we do if we use agonist therapy. The jail that will allow us
to do Vivitrol injections is not real comfortable with
opioid agonists right now so what they allow us to
do is to take the person out of jail, bring them to my office, or bring them to the tribal
clinic, administer the dose, and then put them back in jail. But the naltrexone injection,
we can get that to the nurse and she can take care of that so that’s how we handle
agonists and antagonist therapy. – [Dr. Stein] Okay, so to be clear, you’re not using telemedicine
to deliver MAT in your jail? – [Dr. Morrone] We do it for the visit. – [Dr. Stein] Okay. – [Dr. Morrone] To set it up. But I don’t need to see
the nurse give the shot. We do the telemedicine to qualify the SUD and order the MAT and
then we do the follow-up. How’s it working, how was the shot? And we come back in five to seven days and see how it goes. Kind of a hybrid of both. – [Dr. Stein] Great. Did you have any issues
with accessing technology within the facility or
do you have any advice as to how people can ensure that there is access to technology within
correctional facilities? – [Dr. Morrone] You know, all
the correctional facilities are going to be a little different. We try to work off a mobile WiFi and our laptops and tablets. The best thing you could do is if you start working with a grant, make sure the grant covers the hardware so that you can have telemedicine in place and you don’t have to
come in and set it up. I don’t know how the states and all the jails and
jurisdictions will feel differently but making sure that you
have the proper hardware to get out, using WiFi
is somewhat mitigated with all that concrete and steel. That’s why WiFi is one of our barriers. But if we could get access to IT for the Department of Corrections,
it would vastly improve and that’s our next step
to see if we can get the Department of Corrections to help us increase the quality of
our IT for telemedicine. – [Dr. Stein] Wonderful,
thank you so much. I think you also probably
would, well, I want to pause. Dr. Moore or Dr. Lin, is there anything you would like to add to Dr. Morrone’s comments? Okay, well hearing none, we’ll
move to the next question. This one’s more about court leaders. Can you speak about the role
that court leaders should take in deciding to implement telehealth? – [Dr. Morrone] Court leaders? Sorry, that term, what does that mean? – [Dr. Stein] The full question is can you speak about the role
that court leaders should take in deciding to implement
telehealth in either jails or prisons or diversion programs throughout the court process. And that would be open
to any of our presenters who feel comfortable responding. – [Dr. Lin] Hi, this is Dr. Lin. Yep? – [Dr. Morrone] Go ahead, Dr. Lin. Well, I. – [Dr. Lin] I have a feeling. Yep? Go ahead. – [Dr. Morrone] The
definition of court leader might lead us to take this
in different directions. But all three of us would probably agree that we know judges today
that will totally support medication assisted treatment
that five or 10 years ago had the opposite opinion. And if these are the court
leaders that can help advocate for us with the
Department of Corrections or our local jails, all you have to do is
show them the results. Less recidivism, people get jobs, people’s lives change. If those court leaders can
see that when they come back, almost all the judges we’re
working with in criminal justice had exactly 180 degree
opinions of what we do 10 years ago and they’ve
all changed their mind now that they’ve seen the data. And I open that up to
the other two panelists. – [Dr. Lin] Yeah, I
totally agree with that that sometimes when it comes
to adopting a new practice, right, for example,
telemedicine, like I said, telemedicine’s been done for many decades in many different settings and I imagine that there are probably jails and prisons that have been using telemedicine just for a staffing perspective
for lots of other things. But having the additional
kind of motivation to utilize this newer approach
for medication treatment, I think, having court
leaders, judges, et cetera, be part of that kind of
discussion and that push is really critical. Because it’s hard for
anybody to do anything new, especially within large systems like that. But just having the
additional kind of motivation to say this is something that we need, it’s really hard to get new providers, or providers into jails and prisons, really may be the most
realistic way to do it is through the use of telemedicine, I think would be critical. But then to take the further step back of continuing the push for availability of medication treatment
within jails and prisons. That’s also got to be the first step. – [Dr. Moore] Yeah, I
think I would echo that. I was thinking about a
patient that I treated. I don’t work with folks
that are part of the, that are in the legal system
but every once in a while someone will come into the
clinic and they will come in because they’re maybe facing
charges related to something and they really feel the
need and the pressure and maybe their probation
officer does also to kind of demonstrate that
they’re engaging in care. I’ve heard it multiple times
from patients that maybe they perceive that judges
are looking for treatment, they are looking to see that patients who have an opiate use disorder
are engaging in treatment. I mean, these are the
folks that I kind of, that naturally fleck for my clinic because I’m offering buprenorphine but several times now
I’ve had patients come in and they say they want to go on suboxone because they’re worried
that they may go to jail and they want to kind of
really demonstrate it. That suggests that a number of judges, at least in the
communities that I work in, are supporting it. I don’t know that they’re
looking for telemedicine. There wouldn’t be any options if they didn’t come to my clinic because there aren’t any
other options in those towns. But I think that, I think
this can really be expanded and if once the courts
maybe even start to advocate within their own systems
they can start to have these telemedicine relationships. A lot of interesting things
can be done but yeah. – [Dr. Morrone] I’d like
to give two very short examples of court leaders
and how they change things. We had a problem where the
regulations did not allow a Schedule II to be used in that facility and they went to the county
and the county commissioners and the jail administrator and the sheriff designated a room in jail not jail so that treatment could be in that room because according to the other
rules, that couldn’t happen. Court leaders sometimes is
not a member of the court. In Midland County, the
sheriff came to us directly and said I want 100
Vivitrol shots this year. Can you come over and do it? It’s not that the courts were against it but the sheriff was closer
to the population issues and he was seeing the same
people and the recidivism. In his criminal justice setting, he was pushing the advance
of MAT in his jail. Court leaders can be
different people sometimes. – [Dr. Stein] Well, thank you for that. Okay, so we have reached
the end of the time for Q&A because we have
a few housekeeping slides that we want to visit. However, if your question
was not answered, what we’ll try to do is
work with the presenters to come up with answers and
then disseminate the answers to the remaining questions with the slides for today’s webinar. And yes, the slides will be disseminated directly to everyone
who has been registered for this webinar. And as mentioned earlier,
we will also let you know when the recording for
this webinar is available. Now here we have a slide up for obtaining Continuing Education and this
link that is on the screen is not hyperlinked but we have just posted
it in the chat box, which it is hyperlinked in the chat box. And I just want to pause and see if Steve from our partnership over at RSAT has any comments for this slide. – [Steve] Hi, can you hear me? – [Dr. Stein] Yes, I can hear you. – [Steve] Great. For anyone that’s not familiar
with the RSAT webinars I hold monthly, I know
we have some on the line, but this is a simple 10-question quiz about today’s webinar, about
content from today’s webinar. In order to receive credit
for Continuing Education for the whole 90-minute session, you’ll have to answer a few questions giving us some feedback
on the presentation and answer seven questions correctly out of a 10-question quiz. If you have any issues
or have any questions, feel free to email me. I’ll pop that into the chat box as well for any questions about
Continuing Education for this webinar. Thank you. – [Dr. Stein] Thank you so much, Steve. And we really, again, want
to express our appreciation. RSAT is a BJ, Bureau of
Justice assistance funded technical assistance center and
so we really appreciate them partnering with us on this webinar. If we could move to the next slide. Here we have some additional resources. There was a question about 42 CFR Part 2. A couple of resources
that might be helpful are going to pop up. You should have seen a file transfer box pop up on your screen and
shortly you will see a file name for these two documents come up. These are from SAMHSA and provide a little bit more information about how to think about 42 CFR Part 2 and how it applies to your work. If you click on the file name, the download button should
turn a darker gray color, and you can click on that download button and those documents will then download directly to your computer. You can also go to healthit.gov and these two resources are
also listed on the web there at healthit.gov. We also want to give you a heads up for another opportunity to learn more about how we can leverage technology. The SAMHSA GAINS Center
is going to be hosting a virtual learning
community around technology in the coming calendar year. The name is Utilizing Technology to Increase Service
Engagement and Optimization. This will not just focus on telemedicine but it will look at various technologies that are being applied to
increase service engagement. Please be on the lookout if
you’re on the GAINS listserv. You should see emails coming out. If this a topic of interest to you, then please be watching for emails in the coming calendar year as we kick off this
virtual learning community. And if you’re not on the GAINS listserv, here is a short link that you can copy and enter into your browser
and it will take you directly to a page where you can
sign up for our eNews. We, on a monthly basis,
share articles about programs in across jurisdictions in the
US that are doing great work to move people with mental
health or substance use disorders out of the justice system
into treatment and services. And we also share a lot of information about these types of
webinars and other events coming from the GAINS Center
through our newsletters so please sign up for that. Then finally, if you had a question
that didn’t get answered, please do not hesitate to
reach out to the GAINS Center and if our presenters are in agreement, we could potentially link
you with the presenters if you need to speak with them directly. We could see if they are open to that. Otherwise, we also have in-house staff who can provide phone-based
technical assistance. Feel free to reach out
to the GAINS Center. There’s a website there at
the bottom of the screen as well as our toll free number and so don’t hesitate to reach out. We’ve received funds to provide phone-based
technical assistance to communities across the
country to do this work. With that, we have a
poll that has popped up and we welcome your feedback. If there are any other
technical assistance strategies that you think would be
helpful around this topic, let us know. And we also are interested if
any of the additional topics related to today’s webinar
would be of interest to you so we really appreciate your
participation in that poll. Then finally, thank you so
much to Dr. Lin, Dr. Moore, and Dr. Morrone for your time
and wonderful presentations. We really appreciate what
you’re doing in the field and sharing that work with us today. It’s been very informative
so thank you so much for your time. With that we’ll bring
the webinar to a close. Thank you so much and hope to see you on tomorrow’s webinar. Bye-bye.

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